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SAN 10k,.,,T coiwry PUi uc I1F,Ai,T11 SERVIC. <br /> FNviRUNMEwAL tIFALTiI DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> riiiia ria++ta++aa#aa+art+tft#f+#tar!!#1+tttf#!##t!alaft##t#+t!##+F#!#+1+t!#t#################iF#�•#####4�R4##A4 <br /> i'nhlic I1'e11111 Services Environmental llealth Division Tank Tracking Sheet shall accompany each tank affixed <br /> with it^ aitr idrritification nttmher. The Tank Tricking Sheet is to he returned to Public health Services Environmental Health <br /> Divieinrt wit.11in Jo-days of acreptince of the tank by the disposal or recycling facility. The permit holder- is responsible for <br /> rnsnring that this form is completed and returned. <br /> FA(:11.I,fY NAMTi:_ Tay.� Tours <br /> C.P.A. # CAL 000127922 i <br /> FAClr.rry AiMMIS: 303 E. Kettleman Ln. , Lodi, CA 95240 <br /> TANK i1) N39 p�oZ <07-'� TANK SIZE: /O,aoo PREVIOUS TANK CONTENTS: diesel fuel <br /> �r+a+aa r++iaaa++#tti+#+ttatt#f#t+attar++t#Maafattft#t#t♦#tftttt##fttit#t#!!t!f######!########!#+►###+A#*##### <br /> 2 - f'o be filler)out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe oil 111C. <br /> Arkhrss: 351 N. Beckman lid./P.O. Box 357 City: Lodi, CA Zip- 95241-0357 <br /> Phone 1: ( 209 ) 3613-6 175 Date Tank Removed: <br /> SF(-•I'iON 3 'To be filled out by contractor "decontaminating tank": <br /> tank i)cr:nntaminition Contractor: Jim Tlior-pe Oil, J.ttc. <br /> Address: 351 N. Beckman Rd./P.O. Box 35.1 City: Lodi, CA Zip:95241-0357 <br /> i'honr N ( <br /> 209 ) 36£3-6175 <br /> Amhrnin•rl trpttr-rntativr of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> tnanncr as rcrinired by Cal EPA. J <br /> Flame: (ytA R t i tv �ju Title: Ll P Signature: Date�� <br /> ita t! +i #ttt##! # +�+ !#!t#t ttlittlM!##!#+�!#!!t ! �###### #!#iF• #**###A# #A## ####### <br /> an�C 1 s ree off` a rt s' **** ani c roCCarbon vappors upon delivery to 5c5;ini t <br /> A - r o Ire ;ienrff and dated by an anfi�orized representative of the treatment, storage, or tspos aril ty <br /> acr-r-ptin¢ tank and/or piping. <br /> i'1Clllfy Flalilr.: �iClIt111.7Ct' "il.r'(,.L 1'T'o(111C1.3 <br /> lZartcho Cordova, CA <br /> Address: 12000 Folsoln Blvd. City: zip: 95742_ <br /> 9 16 ) 965-4810 t <br />')ate Tank Received: <br /> r <br />•lamr��,c Title: Signature: bk4-s Date <br /> • <br /> +i+aai++llaia++arta+ttaaattaattttaa���a#t"""t#ttftt+tttttf+#atttttflt#f##ti#ft##!!#f##!+�#!#!i►4�######!###!#### <br /> i <br />"If 71 046 (Revised 9/11/96) Page 10 � <br /> 1 <br />